1. Health Service Provision in Kenya: Assessing Facility Capacity, Costs of Care, and Patient Perspectives Dr Caroline Kisia Action Africa Help - International 26 th Nov. 2014

2. Presentation Outline Background to the Study Study Objectives Methodology Results Conclusions 02/07/20152

3. Background to the Study 02/07/20153

4. Background Kenya’s new Constitution – citizens’ right to health Devolution of healthcare service provision to Counties Limited health care budgets Need for evidence to guide policymaking and resource allocation Multidimensionality of health system functions Comprehensive and detailed assessment of the healthcare system performance rarely occurs 02/07/20154

5. Overview of the ABCE Study A collaborative project between Action Africa Help- International (AAH-I) and the Institute for Health Metrics and Evaluation (IHME), an independent global health research center at the University of Washington, Seattle Launched in 2011 Funded through the Disease Control Priorities Network (DCPN), a multiyear grant from the Bill & Melinda Gates Foundation To comprehensively estimate the costs and cost-effectiveness of a range of health interventions and delivery platforms A Multi-country Study allowing for comparisons 02/07/20155

6. Objectives of the Study 02/07/20156

7. Objectives of the ABCE Study The ABCE project aimed to answer the questions of : –What is the Cost of producing health services? –Who is Accessing these health services? –What Bottlenecks exist to health service delivery expansion –How Equitable is access to health care services? –What Tools exist for real-time monitoring and tracking health sector growth? 02/07/20157

8. Methodology 02/07/20158

9. Study Design Sample design Stratified random sampling - nationally representative sample of health facilities Step 1: Counties from which facilities were drawn were initially grouped into 27 and later into 16 unique categories based on their: Average malnutrition rates – low, middle and high Health expenditures – poor, middle and wealthy Population density - rural, semi-dense and dense Nairobi and Mombasa were automatically included due to their size and relevance to Kenya’s health service provision 18 counties were selected through the county sampling frame Step 2: Entailed sampling facilities from each selected county across the range of platforms i.e. channels identified as offering health services in Kenya. 254 facilities (excluding DHMTs) were randomly selected through the facility sampling frame 02/07/20159

10. Sampling strategy for facilities

11. Data Collection Primary data collection took place from April to November 2012 Four main data collection mechanisms: 1.Existing data 2.ABCE Facility Survey – over 2,600 data elements District Health Management Teams (DHMTs) received a modified version of the ABCE Facility Survey. 3.Clinical chart extractions of HIV-positive patients on ART 4.Patient Exit Interview Survey 02/07/201511

12. ABCE Facility Survey Primary data collection from a nationally representative sample of 254 facilities Collected data on a full range of indicators o Inputs, finances, outputs, supply- side constraints and bottlenecks, indicators for HIV care Randomly sampled a full range of facility types o National and provincial hospitals, district and sub-district hospitals, maternity homes, health centers, clinics, dispensaries, VCT centers, drug stores or pharmacies, and DHMTs

13. Clinical chart extraction Extracted data on HIV-positive patients currently enrolled in ART Chart data included patient demographic information, ART initiation characteristics (e.g., CD4 cell count, WHO stage, drug regimen, referral points), and patient outcomes

14. Patient Exit Interview Survey Over 4,200 structured interviews were conducted with patients after they exited study facilities. Questions included reasons for the facility visit, satisfaction with services expenses paid associated with the facility visit, For the ART sub-sample HIV- specific indicators.

15. Results 02/07/201515

16. Facility capacity and service provision

17. Most facilities provided key health services Service was of varied quality Gaps were identified between reported and functional capacity to provide care depicting an urban-rural divide. Availability of recommended equipment and pharmaceuticals was moderately high, but varied within facility types. Facilities showed higher capacities for treating infectious diseases than non-communicable diseases. Non-medical staff and nurses composed a majority of personnel More urban facilities achieved staffing targets than rural ones. 02/07/201517

18. Facility capacity and service provision Gaps in reported and functional capacity for care Many facilities reported providing a given service, but then lacked the full capacity to provide that service (e.g., lacking functional equipment or stocking out of medications). Service Facilities reporting capacity Facilities with functional capacity Antenatal care89%12% General surgery services58%13%

19. Facility capacity and service provision Capacity for disease-specific case management

20. Facility capacity and service provision Human resources for health: personnel composition

21. Facility production of health services

22. ART patient volumes quickly increased at primary care facilities; other patient visits were more variable over time. Medical staff in most facilities experienced low patient volumes each day. Facilities showed capacity for larger patient volumes given observed resources. ART patient volumes could moderately increase given facility resources, especially for district and sub-district hospitals. 02/07/201522

23. Facility capacity and service provision Outputs: average outpatient visits, by platform, 2007-2011

24. Facility capacity and service provision Outputs: average inpatient visits, by platform, 2007-2011

25. Facility capacity and service provision Outputs: average ART visits, by platform, 2007-2011

26. Efficiency and Cost of Care

27. Efficiency scores across platforms showed wide heterogeneity, particularly within the private sector ranging from below 20% to 100%. On average, efficiency of public health facilities increased along the levels of care, posting dispensaries at 46% and national and provincial hospitals at 75%. In terms of spending, personnel accounted for the vast majority of annual expenditures across facility types. On average, facility costs per patient varied markedly across facility types –cost per outpatient visit ranged from KShs 342 at public dispensaries to KShs 2,825 at national and provincial hospitals. 02/07/201527

28. Efficiency and costs of care Efficiency scores across platforms, 2007-2011

29. Efficiency and costs of care Estimated potential for expanded service production, 2011

30. Patient perspectives

31. Patient Perspectives Most non-HIV patients had medical expenses, whereas few ART patients reported paying for care Most patients spent less than an hour traveling to facilities, whereas waiting times for care varied more Patients gave high ratings for facility providers and slightly lower ratings for facility-based qualities 02/07/201531

32. Non-HIV patient perspectives Patient reports of expenses associated with facility visit, 2012

33. Percent of patients ‘very likely’ to return to this facility if needing health services in the future

34. Conclusions

35. This multidimensional assessment provides a unique perspective on health facility capacity, costs and quality of care. The study indicates that there is room to utilize existing capacity to expand healthcare service provision at a relatively low marginal cost. Further analyses on this front would provide helpful insights towards Kenya’s aspirations of universal health coverage. 02/07/201535

36. Acknowledgements

37. 02/07/201537 This study was made possible through the efforts of a number of institutions and individuals: –The Institute of Health Metrics and Evaluation/UoW – managing the ABCE project grant and providing the technical team for the study –Bill & Melinda Gates Foundation for providing funding –The Ministry of Health, Kenya for supporting the study –The 24 Research Assistants who conducted the field work The co-authors of the abstract from: AAH-I (Ms Ann Thuo), AAH Kenya (Ms Caroline Jepchumba & Dr Githaiga Kamau) IHME-Africa (Prof. Tom Achoki)

38. For further information, below are our contacts 02/07/201538 FAWE House, Chania Avenue P.O. Box 76598 00508 Nairobi, Kenya Mobile: +254 (0) 20 3007755/6 www.actionafricahelp.org